EIN Application Form

EIN APPLICATION FORM

This EIN Application (the "Application") is submitted by Applicant Name: , doing business as Business Legal Name: , with primary business address at Physical Address: . The Applicant requests the issuance of an Employer Identification Number to be used for federal tax administration and related business purposes.

RECITALS

WHEREAS, Applicant Name: is engaged in the business described below and requires a federal employer identification number to comply with federal tax reporting and withholding obligations; and

WHEREAS, Applicant represents that the information provided in this Application is true, complete and accurate to the best of Applicant's knowledge and that Applicant has the authority to request issuance of an EIN for the entity identified herein; and

WHEREAS, Applicant may designate a third-party designee or preparer to receive the EIN on Applicant's behalf and to provide information or execute certifications required by this Application.

NOW, THEREFORE, in consideration of the issuance requested hereby, Applicant submits the following information, certifies to the statements contained in Section 6 (Certification), and agrees to be bound by the representations and obligations set forth in this Application.

1. ENTITY INFORMATION

Sole Proprietor    Corporation    Partnership    LLC    Trust/Estate    Other:

2. RESPONSIBLE PARTY

Responsible Party Name: Title/Capacity:

Responsible Party SSN/ITIN/EIN: Contact Telephone:

3. BUSINESS ACTIVITY AND EMPLOYEES

Date Business Started: Number of Employees Expected This Year:

Reason for Applying (check all that apply):
Started new business    Hiring employees    Banking purposes    Created a trust    Acquired business    Other:

4. THIRD-PARTY DESIGNEE / PREPARER

Applicant designates a third-party designee to receive the EIN and to act on Applicant's behalf regarding this Application: Yes    No

5. NOTICES AND MAILING

6. CERTIFICATION

The undersigned certifies, under penalties of perjury, that the information provided in this Application is true, correct and complete; that the undersigned is authorized to execute this Application on behalf of Applicant; and that Applicant will notify the appropriate tax authorities of any changes affecting the accuracy of this Application. The undersigned further certifies that Applicant will use the EIN only for lawful purposes and in compliance with applicable tax and withholding obligations.

Applicant acknowledges that knowingly submitting false information in this Application may subject the signer to criminal or civil penalties under applicable law, including fines and imprisonment where provided by statute.

I certify under penalty of perjury that I am the responsible party identified in this Application or an authorized representative of the entity named herein and that I have examined the information provided and believe it to be true, correct and complete.

Certification Checkbox: I certify the foregoing.

7. REPRESENTATIONS, WARRANTIES AND INDEMNITY

Applicant represents and warrants that it has the full power and authority to submit this Application and to perform all obligations arising hereunder. Applicant shall indemnify and hold harmless any preparer or third-party designee for any liability, loss or expense arising from Applicant's breach of this Application or from incorrect or misleading information provided by Applicant.

Any disclosure or release of the EIN to third parties shall be governed by Applicant's own policies and applicable law; preparer or designee will not be liable for use of the EIN by third parties after lawful issuance.

8. MISCELLANEOUS

Governing Law: This Application and any dispute arising from it shall be governed by and construed in accordance with the laws of the jurisdiction where Applicant's principal place of business is located, without regard to conflicts of law principles.

Entire Agreement: This Application constitutes the entire agreement between the parties with respect to the matters herein and supersedes all prior oral or written understandings and agreements.

Severability: If any provision of this Application is held to be invalid or unenforceable in any respect, the remainder of this Application shall remain in full force and effect.

Amendments and Waiver: No amendment or waiver of any provision of this Application shall be effective unless in writing and signed by both parties. Failure to enforce any provision shall not constitute a waiver of that provision or any other.

Notices: All notices required or permitted under this Application shall be in writing and delivered to the mailing address provided in Section 5 or to any other address designated in writing by a party.

Counterparts: This Application may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

IN WITNESS WHEREOF, the parties have executed this Application as of the dates set forth below.

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